1. Pharmacology I: Medication Administration
Module 7
Pharmacology I:
Medication Administration

2. Safe Practices in Medication Administration

3. “7 Rights” of Safe Medication Administration
Right Drug
Right Dose
Right Time
Right Route
Right Patient
Right Reason
Right Documentation

4. “7 Rights” (continued) Right Drug Right Dose
Check all orders, labels and confirm that the drug is appropriate for this client/condition
Right Dose
Is the dose is appropriate for the drug, age, size and patient condition

5. “7 Rights” (continued) Right Time Right Route Follow agency policy
Follow medication order and knowledge of appropriate routes for specific drugs

6. “7 Rights” (continued) Right Patient Right Reason Right Documentation
ALWAYS identify the patient 2 ways (the patient’s room number should not be one of the options)
Right Reason
Requires knowledge of medication; knowledge of patient; question appropriateness of order if applicable
Right Documentation
Follow agency policy and procedure for immediate documentation = time, route, response

7. Right Documentation
Remember the 5 W’s when documenting medication administration on chart:
When (time)
Why (include assessment, symptoms, complaints, lab)
What (medication, dose, route)
Where (site)
Was (med tolerated?/helpful to the patient?)
(See Study Guide #2 for additional charting tips and legal aspects of medication documentation)

8. Medication Documentation
First, make sure you have the right chart!
Never chart a drug before it is administered
Documenting includes name of drug, dosage, route, and time
Record location when giving parenteral
medications
Follow agency policy if a medication
was not given
Document client’s response to the
medication

9. Preventing Medication Errors
Minimize verbal and telephone orders
Refrain from attempting to decipher illegibly written orders
Always adhere to the 7 rights
Read the label 3 times, checking against the medication administration record
Listen to the patient - any concerns are the nurse’s concerns!

10. Preventing Medication Errors (continued)
Double check with literature if in doubt about an order
Minimize interruptions while processing and preparing medications
Do not agree to give medications in an area where you are not experienced

11. Nursing Process and Medication Administration
Assessment
Medication history, allergies, ability to take med in the form provided?
Diagnosis
Is this the right drug, dose, patient, etc?
Planning
How will the drug be given?
Implementation
Correct route; need for standard precautions?
Evaluation
Was the medication effective?

12. Patient Assessments in Medication Administration
Assess patient variables that might influence drug therapy.
Assess drug history prior to the start of a new drug
Assess patient’s response to the medication
Assess physical parameters prior to administration
Apical pulse, BP

13. Nursing Responsibilities in Medication Administration
Be knowledgeable about medications being administered and being taken by the patient
Know what to do in the event of an adverse reaction
Verify and clarify orders that seem inappropriate
Be knowledgeable and informed concerning agency policies, especially concerning JCAHO’s National Patient Safety Goals
Follow standards of nursing practice
Observe standard precautions and use medical-surgical asepsis if indicated
Confirm “7 rights” of safe medication administration
Document medication delivery and patient response accurately and appropriately
Report adverse events or incidents per agency policy

14. Medical-Surgical Asepsis and Medication Administration
Medical Asepsis
Handwashing
Standard precautions
Surgical Asepsis
Use of sterile supplies

15. National Patient Safety Goals related to Medication Administration
Use at least 2 patient identifiers just prior to medication administration. (i.e. ask the patient to relate to you their name and date of birth)
Verify verbal or telephone orders by verbally reading back the order to the Licensed Independent Practitioner (LIP) out loud.

16. National Patient Safety Goals related to Medication Administration (continued)
Take action to prevent errors involving sound-alike or look-alike drugs (see agency policy for specific precautions and actions to implement)
Label all medications containers both on and off the sterile field. (This applies to syringes of drawn-up medications to be given later, medication cups of oral medications to be given later, etc.)

17. National Patient Safety Goals related to Medication Administration (continued)
Follow agency policy concerning a comparison of the patient’s currently prescribed medications with those just ordered during the current visit.

18. Legal Implications for Medication Administration
Nurse’s roles and responsibilities for administration of medications are defined and described by standards of care and the Nurse Practice Act
Additionally, there are agency specific policies and procedures

19. U.S. Laws Affecting Medication Administration
Food, Drug & Cosmetic Act – (1906)
Required accurate labeling and testing for harmful effects
1962 added requirement of proof of safety and effectiveness
Harrison Narcotic Act (1914)
Established legal term “narcotic”
Regulated importation, manufacture, sale and use of habit-forming drugs

20. U.S. Laws Affecting Medication Administration (continued)
Durkham-Humphrey Amendment (1952)
Clearly differentiates drugs that can be sold only with a prescription, those that can be sold without a prescription, and those that cannot be refilled without a new prescription.

21. U.S. Laws Affecting Medication Administration (continued)
Controlled Substance Act- (1970)
Also known as: Comprehensive Drug Abuse Prevention and Control Act
In response to growing misuse/abuse of drugs
Categorizes controlled substances
Limits how often a prescription can be filled
Established government-funded programs to prevent and treat drug dependence

22. U.S. Laws Affecting Medication Administration (continued)
Comprehensive Drug Abuse Prevention and Control Act (continued)
Promotes drug education
Strengthens enforcement authority
Establishes treatment and rehabilitation facilities

23. Schedules of Controlled Substances
See schedules Study Guide 5
Give an example of one drug from each category

24. Rules Governing Administration of Controlled Substances
Keep in “burglar” proof containers
Double-locked carts or cabinets
Accurately complete controlled Substance Inventory form
2 nurses must witness and document
when wasting a controlled substance

25. Medication Orders…
Should be written clearly, legibly and in easy-to-understand language
Should be clarified if unclear – check with direct supervisor first.
Should not include blanket, summary statements such as “resume all pre-op orders”

26. Essential Parts of a Medication Order
Patient’s full name
Date and time order written
Name of medication to be administered
Dosage (strength and amount to be given)
Frequency of administration
Route
Number of doses or days medication is to be given
Signature of the ordering physician

27. “Do-Not-Use” Abbreviations
U for unit
IU for international unit
Q.D., qd, QOD, q.o.d.
A trailing zero (i.e. 2.0 mg. Instead use 2 mg)
MS, MSO4, MgSO4
> for greater than
< for less than
Abbreviations for drug names
Apothecary units
@ for at
C.c. for cubic centimeters
Ug for microgram
See Study Guide 7 for more information

28. Sources for Locating Drug Information
Physician’s Desk Reference
National Formulary or Hospital Formulary
Pharmacists
Drug reference books
Pharmacology textbooks
Computer-based Indexes

29. Drug Misuse
Drug misuse - Improper use of any medication which leads to acute/chronic toxicity
Drug abuse - Inappropriate intake of a substance

30. Drug Dependence
Drug dependence - Person’s reliance on or need to take a substance
Physiological dependence – biochemical changes in body tissue, especially the nervous system, which lead to a requirement by the tissues to function normally
Psychological dependence – emotional reliance to maintain a sense of well-being

31. Pharmacokinetics “What the body does to the drug” Absorption
Distribution
Metabolism/Biotransformation
Excretion

32. Pharmacokinetics (continued)
Drug Effects
Onset- Time it takes for a therapeutic response
Peak - Time it takes for maximum therapeutic response
Duration of action - Length of time that drug concentration is sufficient for a therapeutic response

33. 4 Factors Affecting Absorption
Route of administration and conditions at absorption site
Oral medications have slowest rate of absorption
IV drugs the fastest
Drug dosage and form
Enteric coatings delay absorption
Liquid form absorbed faster than pills
Some parenteral/topicals have additives that delay/prolong absorption

34. Factors Affecting Absorption (continued)
Fat (lipid) solubility
More lipid soluble the more rapid it’s absorption
Gastrointestinal factors
Gastric emptying time
Motility - diarrhea, constipation
Presence of food
Integrity of GI tract

35. 4 Factors Affecting Distribution
Blood flow
Plasma protein binding
Amount of the drug
Physiological barriers to absorption
Blood-brain-barrier
Placental barrier

36. 4 Factors Affecting Metabolism/Biotransformation
Condition of the liver
Liver filters most medications
Age
Infants and elderly usually have decreased metabolism of drug
Nutritional status
malnutrition
Hormones

37. 2 Factors Affecting Excretion
Renal excretion
Drugs are filtered in or out by kidneys
Renal pathology will decrease excretion
Decreased excretion increases circulating
blood levels of the drug
Liver or lung pathology

38. Drug Half-Life
The time it takes for ½ of the original amt of the drug to be removed from the body
Useful for determining amount of drug in blood level in relation to amount removed by elimination
Used to determine the frequency of drug administration

39. Pharmacodynamics “How the drug affects the body”
Biological, chemical, and physiologic actions of a drug within the body
Drugs can promote, block, or turn on/off a response
They cannot create a new response

40. Loading Dose
A loading dose is one that is larger than the standard dose:
It is given at the beginning of drug therapy to quickly raise the blood level of the drug into therapeutic range.
It is used when the desired therapeutic response is required more quickly than can be achieved with the standard dose.

41. Maintenance Dose
A maintenance dose is one that continues to keep the drug in the desired therapeutic range:
It is used after a loading dose.
For many drugs, patients receive the maintenance dose both at the start of therapy and throughout therapy.

42. Therapeutic Index
Relates to drug’s margin of safety, the ratio of effective dose to a lethal dose

43. Tolerance
Means that a larger dose is needed to bring about the same response

44. Adverse Effect
Any non-therapeutic response to the drug therapy-consequences may be minor or significant

45. Drug Interactions
Action of one drug on a second drug or other element creating one or more of the following:
Increased or decreased therapeutic effect of either or both drugs
A new effect
An increase in the incidence of an adverse effect

46. Causes of Drug Interactions
GI absorption
Enzyme induction
Renal excretion
Pharmacodynamic effects
Patient care variables

47. Allergic Reactions
Allergic reactions are altered physiologic reactions to a drug that occur because a prior exposure to the drug stimulated the immune system to develop antibodies.
Anaphylaxis is the most serious allergic reaction.

48. Accumulation
Occurs when the dosage exceeds the amount the body can eliminate through metabolism and excretion
Is called toxicity if tissue/organ damage occurs
Factors contributing to accumulation:
Age
Underlying disease

49. Toxicity: Evaluating Drug Levels
When receiving certain medications, blood samples are drawn to maintain blood levels within a therapeutic margin
Peak: draw a peak level 30 min after IV administration and 1 hour after IM administration
Trough: draw a trough level just before the next dose (sometimes before the 3rd dose)

50. Nursing Responsibilities for Toxicity
Assess for signs of:
Ototoxicity: balance and hearing
Nephrotoxicity: I & O, proteinuria
GI toxicity: diarrhea
Neurotoxicity: drowsiness, seizures

51. Patient Teaching
To grant legal consent to treatment, patients must be informed about drug regimen
Assess patient’s knowledge of medication
Provide information about purpose of drug, action and side effects
Teach how to self-administer
drugs and incorporate into
daily routines

52. Route of Administration
Depends upon:
Drug characteristic
Desired responses
Each route has advantages/disadvantages

53. Oral Route Simple and convenient Relatively inexpensive
Can be used by most people
Disadvantages:
Slower drug action
Irritation of GI tract

54. Oral Administration Assess patient Can the patient swallow?
Crush tablets if appropriate
Don’t crush enteric coated or time-released capsules
Crushed tablets may be mixed with food

55. Oral Administration (continued)
Preparation
Solid medications can be put in the same cup except when special assessment like blood pressure or apical pulse is required
Unit dose can be kept in original package
Always place bottle or container caps upside down on counters or tables

56. Oral Administration (continued)
Liquid medications
Shake to mix
Pour away from the label
Use the appropriate measuring device
like a medicine cup or syringe
Avoid alcohol based meds with alcohol addicted persons
Use a straw for liquid iron preparations

57. Sublingual and Buccal Administration
Prevents destruction in the GI tract
Allows rapid absorption into the bloodstream
Sublingual tablets placed under the tongue; buccal tablets placed between upper or lower molars in cheek area (alternate sides)
Instruct patient to allow medication to dissolve & not drink until completely dissolved

58. Topical Administration
Primarily provides local effect
Clean off old medication
Apply using appropriate device
Special Considerations
Nitroglycerine (NTG)
Transdermal Meds

59. Rectal Administration
Assess the patient
GI function and Anal Competence
Keep suppository in refrigerator until ready to administer
Place patient in left lateral position
Lubricate the suppository
Insert past the internal sphincter
For enemas, have them retain for 20 to 30 minutes.

60. Vaginal Administration
Cleanse perineum
Insert applicator 2 inches
Cleanse patient after administration

61. Inhalant Administration
Check vital signs
Have patient exhale deeply
before activating device
Have patient close lips around the mouthpiece without touching it
Use spacer device when needed

62. Nasal Administration Have patient blow nose
Have patient keep head back
Push up tip of nose
Place tip of administration device slightly inside nose
May cause aspiration

63. Ophthalmic (Eye) Administration
If possible, use warm solution
Administer with patient supine or sitting up with head back
Have patient look up
Place drop in conjunctival sac
Have patient blink to distribute the medication

64. Otic (Ear) Administration
Position patient with affected side up
Straighten ear canal up and back
Adult: up and back
children under 3: pull down and back
Warm the solution slightly
Mineral oil is sometimes used in advance to soften wax prior to flushing.
Instill drops into the ear canal

65. Parenteral Route Refers to any route other than gastrointestinal
Commonly: SC, IM, IV Injections
Must be prepared, packaged and administered to maintain sterility
Multi-dose vials
Single dose vials

66. Parenteral Administration
Equipment
Use only sterile needles and syringes
Needles and syringes are available in various gauges and volumes. The larger the syringe the lower the injection pressure
For volumes < 1 ml, use TB or I ml syringe
Use an insulin syringe for insulin

67. Equipment for Injections
Choice of needle gauge depends upon:
Route of administration
Viscosity of the solution
Size of the client
Usually: 25-gauge 5/8 inch needle SC and Intradermal
20-or 22-gauge, 1½ inch needle for IM

68. Medications in Ampules & Vials
Ampules are sealed glass containers
The top is broken; medication is removed by needle & syringe (use a filter needle)
Unused portions must be discarded
Vials with powdered form, follow directions to dilute with sterile water or normal saline

69. Subcutaneous Administration (SQ)
Injection of drugs under the skin
Used for small volume (1 ml)
Absorption is slower
Drug action is usually longer
Drugs that are irritating to tissues
cannot be given SC
Common sites:
upper arms, abdomen, thighs
Photo Source: Lippincott, Williams & Wilkins, Connection, Image Bank,

70. Subcutaneous (continued)
Use gauge needle
Gather tissue in opposition and pull up slightly
Insert needle at 45 or 90 degree angle using a pushing action
Do not aspirate
If anti-blood clotting agent, do not massage site

71. Intradermal Administration (ID)
Use gauge needle
Apply traction to skin near site
Place needle with bevel upward
Inject small wheel at site and
withdrawal needle
Do not massage
Maximum volume = 0.1ml
Photo Source: Lippincott, Williams & Wilkins, Connection, Image Bank,

72. Intramuscular Administration (IM)
Involves injection of drugs into muscle
Absorption is more rapid due to blood supply
Incorrect injection techniques may damage blood vessels and nerves
Photo Source: Lippincott, Williams & Wilkins, Connection, Image Bank,

73. Intramuscular Injection Sites
Dorsogluteal
Ventrogluteal
Deltoid
Vastus Lateralis
Photo Source: Lippincott, Williams & Wilkins, Connection,
Image Bank,

74. Intramuscular Administration
Use 21-22g needle
Insert at 90 degree angle
Max volume 5 ml; usually doses of 1-3 ml

75. Intramuscular Administration
Z-Track
For solutions irritating
to the tissues
Pull skin away from site to displace tissue
Inject medication
Don’t massage after injection
Photo Source: Lippincott, Williams & Wilkins, Connection, Image Bank,

76. Intravenous Administration (IV)
Involves injection of drugs directly into bloodstream
Drugs act rapidly
Administered through established IV line or direct injection into the vein (in emergencies)
Used for intermittent or continuous
infusions

77. Intravenous Administration (continued)
Advantages:
Client comfort
Easy access for nurses
Disadvantages:
Time and skill required for venapuncture
Difficulty in maintaining an IV line
Greater potential for adverse reactions
Possible complications of IV therapy

78. Intravenous Administration (continued)
Assess IV insertion site:
Pain
Redness
Bleeding
Swelling
Dressing dry and intact
Photo Source: Lippincott, Williams & Wilkins, Connection, Image Bank,

79. Nursing Care with IV Medications
Use standard precautions
Wipe “port” with alcohol before accessing
Strict sterile technique when preparing medication
New guidelines require IV securing device, transparent dressing or sterile tape to secure catheter to the patient

80. Nursing Care (continued)
When discontinuing IV catheter on a client on anticoagulants, prolonged pressure may be required
Document as per policy

81. Intravenous Piggyback (IVPB)
IVPB is a small volume of medication that is attached or “piggybacked” into the port of an existing IV line
Alcohol the port before attaching the piggyback tubing

82. Intermittent IV Therapy
Patient may have a saline lock (heparin lock) without a primary IV running through it
Used just for intermittent medications
Flush before and after medication with normal saline

83. Intravenous Push (IVP) Administration
The medication is pushed into the port by the nurse
Before pushing, the nurse must know:
If the medication is compatible with the existing IV fluid
The rate that the push should be given
usually in minutes

84. Intravenous Administration - Equipment
Pumps
Deliver in ml/hour; most pumps deliver to the tenths place (ex: 85.5 ml/hour)
Check IV site before connecting to pump
Set rate according to physician’s order
Check for kinks or obstructions frequently

85. Central Lines
Terminate in the jugular vein, subclavian vein, brachial vein or even into the right atrium
Strict sterile technique must be followed when accessing these
Sterile gloves, masks
Peripheral intravenous infusion catheter (PICC)

86. Calculating Dosages And the answer is…. Practice the following:
Dose on hand = 250mg
Quantity on hand: 1 tablet = 250mg
Desired dose (dose ordered) = 500mg
?? = # of tablets required
And the answer is….

87. Calculating Dosages (continued)
= (cross multiply and divide) x
500/250 = 2
The answer is 2 tablets

88. Calculating Dosages (continued)
Practice the following (requires conversion):
Dose on hand = 250mg
Quantity on hand: 1 capsule = 250mg
Desired dose (dose ordered) = 0.5gm
?? = # of tablets required
And the answer is….

89. Calculating Dosages (continued)
Convert 0.5gm to mg. 1 gm = 1000mg so 0.5 gm = 500mg
= (cross multiply and divide) x
500/250 = 2
The answer is 2 tablets

90. Calculating Dosages (continued)
Practice the following (units):
Dose on hand = 10,000 units
Quantity on hand: 10,000 units per 1 ml
Desired dose (dose ordered) = 5000 units
?? = # of ml required
And the answer is….

91. Calculating Dosages (continued)
5,000 units = x (cross multiply and divide)
10,000 units = 1
5000/10,000 = ½ or 0.5
The answer is 0.5 ml

92. Calculating Dosages (continued)
Practice the following (dose based on weight):
Medication order: Lovenox 1mg/kg BID
Dose/quantity on hand = 80mg/ml
Patient’s weight = 154 pounds
?? = # of ml required
And the answer is….

93. Calculating Dosages (continued)
Convert pounds to kilograms (2.2 lbs = 1 kg)
154/2.2 = 70kg
1mg x 70kg = 70mg
Cross multiply and divide:
80mg = 70mg  70/80 = 0.8
1ml = x
The answer is 0.8 ml

94. Photo Acknowledgement: All unmarked photos and clip art contained in this module were obtained from the Microsoft Office Clip Art Gallery.